With CARRFS Interview wehighlight new insights in public health surveillance and related topics through in-depth interviews with leading public health authorities and experts.

CARRFS eNews talked with Dr. David L. Mowat, Medical Officer of Health, Region of Peel, Ontario about Built Environment in the context of social determinants of health.

How would you describe or define “built environment”?

Within the determinants of health, we have a number of environments - political, social, and economic. To this list, I would add the built environment. These environments overlap, of course, and consist of factors that go beyond the individual. In built environment, we have housing and the infrastructure that supports it - transportation, workplaces, and public spaces. In other words, everything that we have built in and around our cities. All of these influence health. And, the natural environment also plays a role. Within cities, we have playgrounds, open spaces, parks, trees, and so on. They also play a part of the urban form. All these have an impact on health in a number of complex and intertwined ways.

As you know - what’s measured gets attention. Region of Peel has defined built environment around seven elements: density; proximity to services and transit; land use mix; street connectivity; road networks and sidewalk characteristics; parking; aesthetics and human scale. How did you select these elements?

We developed these elements in partnership with Dr. Jim Dunn at the Centre for Research on Inner City Health, St. Michael's Hospital. His team reviewed the empirical evidence connecting the elements of land use planning using the “realist review” methodology. They identified seven elements most strongly linked to health outcomes and constructed the index around them. They then developed quantitative measures of each element after a strength-of-evidence analysis was done for each. Research-based benchmarks, expert recommendations and similar indices (such as LEED-ND) were used to help set targets. Then there was a consultation process to assess feasibility and test its validity in existing communities in Peel.

We know that population density is really important. You need a certain level of density to be able to have viable basic public transit – say a local bus route. For other forms of transit, like an LRT [Light Rail Transit] or subway, you need greater density. The mix of land use, together with density, is reflected in proximity – how close you are to the places you need to go – work, school, stores, services, and so on. Active transportation requires destinations to be close enough to walk or cycle. And not a lot of people are going to walk or cycle in a low-density environment which is 100% residential. It won’t happen. Unfortunately we have, for a long time, built low-density car-dependent urban environments which can’t support transit and active means of transportation.

"The physical activity we do going about our daily life has been engineered out of our lives and we need to put it back it."

Should we care? Yes! In order to solve or prevent potential future health care crisis in the form of obesity, cardiovascular diseases, or diabetes, physical activity, has become an important factor for improving the health status of a population. Normally, when I say physical activity people’s immediate reactions are: “I have to hit the gym” or “We should build more bike paths.” Most people think first of recreational physical activity. I would group physical activity into four types: physical activity at home; physical activity at work; physical activity getting between home and work; and recreational activity.

The only one that has not gone down over the last 30-40 years is recreational activity. In other words, recreational activity is not the problem. The problem is that we have lost the physical activity from our day-to-day life. Our days don’t contain enough physical activity. And most Canadians do not engage enough in regularly recreational activities either. It is a great thing and should be encouraged, but it’s not the problem. The problem is utilitarian physical activity - the physical activity we do going about our daily life. It has been engineered out of our lives and we need to put in back in.

How have you, as a medical officer of health in the Region of Peel, managed to get health on the agenda for the city planners?

It has been an interesting journey. We started out thinking “what on earth are these planners doing?” After starting to talk to them, we realized that they knew a lot more about this than we did. What gets built is the result not just of what constitutes good planning, but also of political and economic forces that have to be balanced. Planners are interested in having us talk about what you might call the “health justification” for complete and compact communities because people believe that health issues are important. This adds to the other reasons why we need good planning – environmental sustainability, economic sustainability, social cohesion, and quality of life. Another issue is building communities for all ages: it’s much better if there is a mix of ages and people can age without having to move when, for example, they can’t drive any longer.

Our elected officials here in Region of Peel - the Council, are very engaged in this issue. They have directed Public Health to work with the regional planning department and municipalities. The political support is there. But it is still a huge challenge – the planning process takes a long time, and in the meantime the GTA is growing fast. In the next 20 years, the GTA’s population will grow by the size of Montreal and Vancouver combined. A lot of that is going to be built on current farmland. At the same time, places like Mississauga and York region are saying “Can’t we improve what we have”? The Province now has rules which force municipalities to intensify and increase density and provide more transportation options rather than only building for cars. So, how do we actually get this solved? One thing we have done in Peel is to develop a health index which is based on the seven elements we discussed. The index has been adopted by our municipalities. What they can do now is to take a developer’s plan for a new subdivision and run it through the index and say – how does your plan score in supporting healthy living?

What are the concrete steps that the Region of Peel is taking?

The prevalence of diabetes is rising very fast. We know that in 2006, one in ten adults in Peel had diabetes. By 2026, it is going to be one in six. A lot is due to aging, some due to ethno-cultural make-up – we know that South Asian and people from the Caribbean have higher risks of diabetes and they are an increasing part of our population. We have to turn this around. Individual behavioural change on its own is not going to do it. We have to change the environment to one that makes healthy behaviours, especially physical activity, possible. We are working with planners and politicians to look at increasing density, doing better on land-use mix, on connectivity, having better infrastructure for cycling and walking with better sidewalks and bike trails. The other thing is that we have to invest in public transit. The typical transit user is going to walk 19 minutes on the outbound journey and another 19 minutes on the home journey. We know that if people use active means of transportation - including transit to get to and from work, we would take a huge step in meeting the recommendation for physical activity of 150 minutes a week - something the majority of the Canadian do not meet today. But if we can get people out of the single occupancy car, we have made a huge impact. Having said that, it is really difficult and definitely a long-term enterprise.

There has been some progress. In the last 10 years, a lot of high-rise development has been built around Square One in Mississauga . Of the population growth that occurs from now on – 40 percent are going to be housed within the existing built boundaries. The goal is to achieve a density of 50 residences plus jobs per hectare over all. In designated city centres like Square One, it has to hit 200 - for downtown Toronto it is already 700. We will see a change with more storefronts on the street, more mixed developments and LRT. Central Brampton will be developed in the same direction.

What role do you see epidemiologists having today and how do you think the profession will evolve over the next 5-10 years?

We are fortunate to have excellent epidemiologists here. I am excited about what they can do for us. There are four epidemiologists, a supervisor, a manager and five data analysts. There are another three epidemiologists and two data analysts for the infectious diseases section. My experience talking to academics is that they are very keen to have the opportunity to solve real problems. We have worked with people from many universities on projects we have funded or received grants, to look at initiatives such as the development of our health index. Another project has been to build “what if” scenarios around e.g. diabetes: What would be the likely impact of increasing physical activity? I find that the information we have been given by the epidemiologists - especially when it has been put into graphic form, can be very persuasive. We need that kind of information to influence stakeholders and politicians. Scenario analysis combined with visualized data is very powerful. Stakeholders listen when you show them – “if you do this, then this will likely happen.”

"I find that the information we have been given by the epidemiologists - especially when it has been put into graphic form, can be very persuasive."

Epidemiologists can go beyond producing data to provide communication tools for decision making. It is not enough to just work in terms of risk factors or mortality/morbidity data but to show: What is this costing us in dollars? How can this be visualized in the form of an info-graphic? Why do we need better transit in the GTA?

Some of the data have we develop ourselves. But we find it helpful if we can link up with epidemiologists in academia and with e.g. Statistics Canada. Statistics Canada is excellent to work with and they have access to datasets which we cannot access ourselves. The Institute for Clinical Evaluative Sciences (ICES) is another example.

But again, producing data costs money. We can’t practice public health without data. It is fundamental. Of a budget of approximately $82 million, we spend about 1.8% on data collection and analysis. It’s a good investment. <>